Meningococcal Conjunctivitis

Itzhak Brook, MD; J.

Bronwyn Bateman, MD;

Thomas H.

Pettit, MD

\s=b\ Meningococcal conjunctivitis is typically described as an acute purulent infection. An atypical case of mild catarrhal conjunctivitis occurred in a 19-year-old college student. The meningococci were identified as Neisseria meningitidis, group A, and were isolated from the throats of the patient and her roommate. The conjunctivitis responded rapidly to

associated with the carrier state.

meningococcal

positive

REPORT OF A CASE

treatment with sodium sulfacetamide, and it was not treated systemically. A short review of the literature of meningococcal conjunctivitis is presented, and the current recommendation for prophylaxis is discussed.

(Arch Ophthalmol 97:890-891, 1979)

meningococcal septicemia. Exogenous meningococcal conjunctivitis, unassociated with systemic infection, has

conjunctivitis occurs /Teningococcal most commonly as a facet of

been described with much less fre quency. Typically, it is described as an acute purulent conjunctivitis with pro fuse discharge. With the advent of readily available, highly effective an tibiotics, the reported incidence of exogenous meningococcal infections has decreased. The following case of isolated mild catarrhal meningococcal conjunctivitis is presented, with epi demiologie data, as a rare infection

Accepted for publication Sept 27, 1978. From the Department of Medicine, Division of Infectious Diseases, and the Department of Ophthalmology, Jules Stein Eye Institute, UCLA School of Medicine, Los Angeles. Dr Brook is now with the Department of Child Health and Development, Children's Hospital National Medical Center, Washington, DC. Reprint requests to Department of Child Health and Development, Children's Hospital National Medical Center, 111 Michigan Ave NW, Washington, DC 20010 (Dr Brook).

A 19-year-old female college student with a four-day history of redness of the eyes and painless discharge was seen in the UCLA emergency center. She had no systemic complaints. Her past medical and ocular histories were unremarkable. Visual acuity was normal. Ocular examination revealed bilateral conjunctival injection of a mild degree with minimal mucoid discharge. The hyperemic conjunctiva showed a diffuse papillary reaction with some follicles. Bilateral preauricular adenopathy was noted. The corneas were clear, the pupils reacted normally, and there were no signs of intraocular inflammation. Cultures were taken and plated promptly on blood and chocolate agar plates for aerobes and blood agar and thioglycolate broth for anaerobes. The patient began receiving 10% sodium sulfacetamide drops bilaterally four times a day. After 24 hours, when the cultures were read as suspicious for Neisseria, the patient was contacted, and she returned to the Jules Stein Eye Clinic. Reexamination revealed a de creased hyperemia and less mucoid dis charge. Throat cultures were obtained from the patient and from seven other close contacts, including her roommate and her boyfriend. On the advice of an infec tious disease consultant, it was elected not to treat the patient systemically. She was informed of the situation and observed closely by our service. The conjunctivitis responded rapidly to treatment, and after five days of therapy, the sodium sulfacet amide eyedrops were discontinued. Neis seria meningitidis', group A, grew on the initial conjunctival culture. This typing was confirmed by referral of the culture to the Center for Disease Control in Atlanta. Repeat conjunctival and throat cultures were done at 5, 10, 14, and 21 days. All follow-up cultures of the conjunctiva were negative. The throat cultures of the patient were positive for the same species, and they remained so for 14 days. The throat cultures of the patient's roommate were

to the tenth day. She was not treated for the carrier state. Systemic dis ease did not develop in the patient or her positive contact. The throat cultures of the six other close contacts of the patient and her roommate were negative for Neisser-

COMMENT

isolated infection and associated with meningococcemia, appeared at the turn of the century as bactriologie methods for isolation improved. Stuart and McWalter,1 reviewing the literature from 1916 to 1943, found six studies reporting isolated meningo coccal conjunctivitis. Reports of the disease were more frequent in the 1940s. Theodore and Kost2 reported eight cases, five culture-positive, of meningococcal conjunctivitis in army personnel during an epidemic of meningococcal meningitis. DeBord' reported one case of conjunctivitis in a man, although there was no descrip tion of ocular or systemic symptoms. Thygeson,4 Bauer et al,5 and Allen and Erdman" described primary meningo coccal conjunctivitis in four healthy adults during this period. Reid and Bronstein,7 Mangiaracine and Pollen," Stuart and McWalter,1 Shuttleworth and Benstead," Lewis and Ferris,'" Gray and Lambert,41 and Kahaner and Lanou12 reported 20 documented cases in infants and children. In 1955, Miller" reported the dis ease in a 4-year-old boy. In 1972, Hausman14 described the disease in an infant.

Conjunctivitis occurring concomitantly with meningococcemia is well documented.1 Reports of isolated cases of meningococcal conjunctivitis are uncommon, and they are found less frequently in the recent litera ture. The earliest reports of meningo coccal conjunctivitis, both as an

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Whether this trend reflects a true decrease in the incidence, possibly related to the modern ubiquitous use of antibiotics, is speculative. The pres
ent case,

example of
ness.

therefore, represents
a

an

process, both in its occurrence in a young adult and in its clinical mild

relatively

rare

disease

studies of described in the literature. Mangiaracine and Pollen* reported a unilateral meningococcal conjunctivitis in a 7-month-old infant and a positive culture of the mother's nasopharynx. Kahaner and Lanou12 reported the disease in a 9-month-old infant and a positive culture in the mother. Gray and Lambert," in reporting a unilateral meningococcal conjunctivitis in a 3%-year-old boy, examined the nasopharynges of the boy's parents and of five sisters, with out evidence of a carrier state. Lewis and Ferris,10 in reporting a case in a 7-month-old girl, found the same group of meningococcus in the naso pharynx of an uncle. Stuart and McWalter,1 in a report of six cases of meningococcal conjunctivitis in chil dren, investigated the family mem bers of three patients. They found one case with a positive nasal swab from the mother. Our case in a 19-year-old college student demonstrated the presence of meningococci in the throat of the patient and of her roommate. The mechanism of transmission for the patient's conjunctivitis may have been her own nasopharynx with contamina tion of the conjunctiva. Other possibil ities include direct airborne transmis sion or manual contact. To our knowl edge, meningococci have never been reported in the normal flora of the

Several

positive

epidemiologie
are

meningococcal meningitis developed after a culture-proven con junctivitis. The chemoprophylaxis of contacts of meningococcal diseases has been extensively investigated in the last
the organism was a sulfonamidesensitive strain.17 Group A organisms usually are not sensitive to these agents. The other groups demonstrate a more variable response. With the slow but steady emergence of resist ant strains,18 numerous other chemoprophylactic agents were tried, but
two decades. Sulfonamides were con sidered to be most effective, providing

in whom

quent to the conjunctivitis. Dillman,1" in 1967, reported the case of a solider

gococcal meningitis developed subse

an outbreak of meningitis, appro priate bacterial cultures of all cases of conjunctivitis would seem warranted to assess the possible role of the conjunctivitis in the epidemiology of

this disease.

Nonproprietary

Name and Trademarks of Drug

cases

RifampinRifadin, Rimactane.
References
1. Stuart RS, McWalter D: Primary meningococcal conjunctivitis in children. Lancet 1:246-249, 1948. 2. Theodore FH, Kost PF: Meningococcic conjunctivitis. Arch Ophthalmol 31:245-247, 1944. 3. DeBord GG: Species of the tribes Mimeae, Neisserieae, and Streptococceae which confuse the diagnosis of gonorrhea by smears. J Lab Clin Med 28:710-714, 1943. 4. Thygeson P: Primary meningococcic conjunctivitis treated by sulfadiazine. Am J Ophthalmol 27:400-401, 1944. 5. Bauer CE, Gall EA, Cox CD: Meningococcal conjunctivitis: A report of three cases. Milit Surg 95:24-27, 1944. 6. Allen JH, Erdman GL: Meningococcic conjunctivitis. Am J Ophthalmol 29:721-723, 1946. 7. Reid RD, Bronstein LH: Meningococcic conjunctivitis. JAMA 124:703, 1944. 8. Mangiaracine AB, Pollen A: Meningococcic conjunctivitis. Arch Ophthalmol 31:284-288, 1944. 9. Shuttleworth FN, Benstead JG: Primary meningococcal ophthalmia. Br Med J 2:568-569, 1947. 10. Lewis N, Ferris AA: A case of primary meningococcal conjunctivitis. Med J Aust 1:621\x=req-\ 622, 1948. 11. Gray JDA, Lambert RA: Meningococcal conjunctivitis. Br Med J 1:17-18, 1949. 12. Kahaner JR, Lanou WW: Exogenous meningococcic conjunctivitis. NY State J Med 45:1687-1688, 1945. 13. Miller H: Neisseria meningitidis isolated from case of acute conjunctivitis. Public Health Rep, No. 1010, 1955 14. Hausman D: Neonatal meningococcal conjunctivitis. Br Med J 1:748, 1972. 15. Reese FM: Meningococcus conjunctivitis followed by septicemia and beginning meningitis. Am J Ophthalmol 19:780-782, 1936. 16. Dillman CE: Meningococcemia after meningococcal conjunctivitis. South Med J 60:456, 1967. 17. Kuhns DM, Nelson CT, Feldmann HA: The prophylactic value of sulfadiazine. JAMA 123:335-339, 1943. 18. Fraser DW, Thornsberry C, Feldman RA: Trends in meningococcal disease. J Infect Dis 125:443-446, 1972. 19. Deal WB, Sanders E: Efficacy of rifampin in treatment of meningococcal carriers. N Engl J Med 281:641-645, 1969. 20. Devine LF, Johnson DP, Hageman CR: The effects of minocycline on meningococcal nasopharyngeal carrier state in naval personnel. Am J Epidemiol 93:337-345, 1977. 21. Vestibular reactions to minocycline\p=m-\ follow-up. Morbidity and Mortality Weekly Report 24:55-56, 1975. 22. Artenstein MS: Prophylaxis for meningococcal disease: Commentary. JAMA 231:1035\x=req-\ 1037, 1975. 23. Eickhoff TC: Meningococcal prophylaxis. JAMA 234:150-151, 1975. 24. Finely RA: Prophylaxis against meningococcal disease. JAMA 236:459-461, 1976.

conjunctiva.
an

The disease has been described

acute

as

minimal lid edema and mild conjuncti val injection with mucoid discharge. Our patient suffered no permanent ocular sequelae, nor did meningococcal septicemia develop. Three reports of meningococcal septicemia have been published, in which there was a defi nite antecedent history of conjunctivi tis. Reese15 reported the case of a 19-year-old nurse in whom conjuncti vitis developed after she had been caring for a patient with meningococ cal meningitis. Meningococcal septi cemia and meningitis subsequently developed. One of the cases described by Mangiaracine and Pollen8 was that of a 15-year-old boy in whom menin-

purulent conjunctivitis occur ring either unilaterally or bilaterally. Our case is atypical, as the patient had

carrier state. This case demonstrates that mild forms of meningococcal conjunctivitis occur, but the frequency is unknown, as most cases of conjunc tivitis are not cultured. It seems unlikely that mild conjunctivitis is an important element in the epidemiolo gy of meningococcal disease. Treat ment for the ocular infection is indi cated. Prophylaxis for the carrier state, a controversial issue, should be considered under epidemic circum stances and for those individuals at higher risk of contracting the sys temic disease, such as infants and young children. In an endemic area or in the face of

reported. A recent recommendation by Artenstein22 in not to treat contacts prophylactically unless the organism is sensitive to sulfonamides. He suggested that close contacts should be observed carefully and treated promptly when meningococcal disease develops. A differing opinion was offered recently by Eickhoff,21 who recommended rifampin for chem oprophylaxis of contacts, and by Fine ly,24 who has recommended the use of sulfonamides and rifampin concur rently as chemoprophylaxis. Meningococcal conjunctivitis, al though presently rare as an isolated ocular infection, should be considered a concomitant of the meningococcal

effective.1920 The untoward side ef fects of minocycline hydrochloride, a tetracyclic analogue, include vestibu lar symptoms, which tend to interfere with compliance and may mimic meningeal signs. Rifampin, which has neither of these side effects, is currently recommended by the Center for Disease Control to be used as a prophylactic agent in epidemic cir cumstances.21 The emergence of re sistant strains to this drug has been

only two, minocycline hydrochloride and rifampin, have been shown to be

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